OMB Approved No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
BREAST CONDITIONS AND DISORDERS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF
COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.
(First, Middle Initial, Last)
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire
as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A DISORDER OF THE BREAST(S)?
(If "Yes," complete Item 1B)
YES
NO
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. If there is no diagnosis, if the diagnosis is different from a previous
diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the Remarks section. Date of diagnosis can be the date
of the evaluation if the clinician is making the initial diagnosis, or an approximate date is determined through record review or reported history.
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO THE BREAST(S)
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE BREAST(S), LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S BREAST CONDITION
2B. DOES THE VETERAN HAVE, OR HAVE A HISTORY, OF A NEOPLASM OF THE BREAST?
(If "Yes," complete Items 2C and 2D)
YES
NO
2C. IS OR WAS THERE A MALIGNANT NEOPLASM?
(If "Yes," indicate which breast):
YES
NO
RIGHT
LEFT
BOTH
(If "Yes," were there or are there currently any metastases?):
YES
NO
(If "Yes," describe locations):
2D. IS OR WAS THERE A BENIGN NEOPLASM?
YES
NO
(If "Yes," indicate which breast):
RIGHT
LEFT
BOTH
SECTION III - TREATMENT/SURGERY
3A. HAS THE VETERAN COMPLETED ANY TYPE OF TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT
NEOPLASM AND/OR METASTASES?
YES
NO; WATCHFUL WAITING
(If "Yes," indicate treatment type(s) - check all that apply):
Surgery
If checked, describe:
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
RIGHT
LEFT
BOTH
Side
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
(describe):
Other therapeutic procedure and/or treatment
Date of procedure:
Date of completion of treatment or anticipated date of completion:
VA FORM
21-0960K-1
SUPERSEDES VA FORM 21-0960K-1, OCT 2012,
Page 1
SEP 2016
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
BREAST CONDITIONS AND DISORDERS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF
COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.
(First, Middle Initial, Last)
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire
as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A DISORDER OF THE BREAST(S)?
(If "Yes," complete Item 1B)
YES
NO
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. If there is no diagnosis, if the diagnosis is different from a previous
diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the Remarks section. Date of diagnosis can be the date
of the evaluation if the clinician is making the initial diagnosis, or an approximate date is determined through record review or reported history.
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO THE BREAST(S)
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE BREAST(S), LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S BREAST CONDITION
2B. DOES THE VETERAN HAVE, OR HAVE A HISTORY, OF A NEOPLASM OF THE BREAST?
(If "Yes," complete Items 2C and 2D)
YES
NO
2C. IS OR WAS THERE A MALIGNANT NEOPLASM?
(If "Yes," indicate which breast):
YES
NO
RIGHT
LEFT
BOTH
(If "Yes," were there or are there currently any metastases?):
YES
NO
(If "Yes," describe locations):
2D. IS OR WAS THERE A BENIGN NEOPLASM?
YES
NO
(If "Yes," indicate which breast):
RIGHT
LEFT
BOTH
SECTION III - TREATMENT/SURGERY
3A. HAS THE VETERAN COMPLETED ANY TYPE OF TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT
NEOPLASM AND/OR METASTASES?
YES
NO; WATCHFUL WAITING
(If "Yes," indicate treatment type(s) - check all that apply):
Surgery
If checked, describe:
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
RIGHT
LEFT
BOTH
Side
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
(describe):
Other therapeutic procedure and/or treatment
Date of procedure:
Date of completion of treatment or anticipated date of completion:
VA FORM
21-0960K-1
SUPERSEDES VA FORM 21-0960K-1, OCT 2012,
Page 1
SEP 2016
WHICH WILL NOT BE USED.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION III - TREATMENT/SURGERY
3B. HAS THE VETERAN UNDERGONE BREAST SURGERY?
YES
NO
(If "Yes," indicate procedure type and severity (check all that apply)):
(For VA purposes, wide local excision means removal of a portion of the breast tissue and includes partial mastectomy,
Wide local excision
lumpectomy, tylectomy, segmentectomy, and quadrantectomy)
Right
Left
Both
(or total)
(For VA purposes, a simple (or total) mastectomy means removal of all of the breast tissue, nipple, and a small portion
Simple
mastectomy
of the overlying skin, but lymph nodes and muscles are left intact)
Right
Left
Both
(For VA purposes, a modified radical mastectomy means removal of the entire breast and axillary lymph nodes, in
Modified radical mastectomy
continuity with the breast, with pectoral muscles left intact)
Right
Left
Both
(For VA purposes, radical mastectomy means removal of the entire breast, underlying pectoral muscles, and regional lymph
Radical mastectomy
nodes up to the coracoclavicular ligament)
Right
Left
Both
Axillary or sentinel lymph node excision
Right
Left
Both
Significant alteration of size or form
Right
Left
Both
Biopsy
Right
Left
Both
Other:
Right
Left
Both
(e.g., arm swelling, nerve damage to arm)?
3C. ARE THERE ANY RESIDUAL CONDITIONS CAUSED BY THE BENIGN OR MALIGNANT NEOPLASM OR ITS TREATMENT
YES
NO
(If "Yes," briefly describe the conditions and complete appropriate Questionnaire):
SECTION IV - OBJECTIVE FINDINGS AND RESIDUALS
4. DID THE SURGERY OR RADIATION TREATMENT RESULT IN THE LOSS OF 25 PERCENT OR MORE TISSUE FROM A SINGLE BREAST OR BOTH BREASTS IN
COMBINATION?
YES
NO
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
5A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION?
YES
NO
(If "Yes," are any of the scars painful or unstable; have a total area equal to or greater than 39 square cm (6 square inches) or are located on the head, face or neck?)
YES
NO
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire.)
(If "No,' provide location and measurements of scar in centimeters.)
Location:
Measurements: Length
cm X width_
cm.
NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations and measurements
in the Remarks section below. It is not necessary to also complete a Scars DBQ.
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
YES
NO
(If "Yes," describe - brief summary):
SECTION VI - DIAGNOSTIC TESTING
NOTE - If imaging and/or diagnostic test results are in the medical record and reflect the veteran's current condition, repeat testing is not required.
6. HAS THE VETERAN HAD IMAGING AND/OR DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT FINDINGS AND/OR RESULTS?
YES
NO
(If "Yes," provide type of test or procedure, date and results - brief summary):
Page 2
VA FORM 21-0960K-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S BREAST CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe the impact of each of the veteran's breast conditions, providing one or more examples)
YES
NO
SECTION VIII - REMARKS
(If any)
8. REMARKS
SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE
9B. PHYSICIAN'S PRINTED NAME
9C. DATE SIGNED
9D. PHYSICIAN'S PHONE AND FAX NUMBERS
9E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
9F. PHYSICIAN'S ADDRESS
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
IMPORTANT - Physician please fax the completed form to:
(VA Regional Office FAX No.)
NOTE - A list of VA Regional Office FAX Numbers can be found at
www.benefits.va.gov/disabilityexams
or obtained by calling 1-800-827-1000.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies,
the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of
VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension,
Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN
to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information
is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN
unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered
relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is
subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.
Page 3
VA FORM 21-0960K-1, SEP 2016
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